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mobilitymgmt.com4 2014-2015 Seating & Positioning H A N D B O O K

contents

Cover Story

Getting Lost in Gravity?The science behind center of gravity and how to get the right

adjustment. Plus: How important is gravity in seating, anyway?

Cover Story

Width + Depth + HeightClinicians and ATPs want systems that fi t well right now; payor

demand built-in growth for system longevity. How can these

different needs be balanced? Plus: Five-year funding for cushions?

Product Revue

New Positioning for 2015!

Ad Index

5

9

13

14

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A Supplement to

mobilitymgmt.com Seating & Positioning H A N D B O O K 2014-2015 5

Gravity isn’t something many of us think much about. We know the story of Isaac Newton and the apple, of course, and we might recall that gravity is responsible for how much we weigh. But we rarely consider the part gravity plays in our everyday lives.

Gravity, as it were, is pretty important for people who use manual and power wheelchairs because gravity can greatly impact a wheelchair setup. In fact, center of gravity (CoG) may be one of the most important adjustments a clinician can make to a wheelchair.

“It’s a foundation measurement that many other measurements fl ow from and are affected by,” explains Jeff Adams, president/CEO of Icon Wheelchairs. “Changes in cushion height, growth, weight gain, weight loss, skill development and others can all have profound effects on the CoG setting and vice versa.”

Yet as important as this measurement is, CoG is often one of the toughest measurements to get right, partly because CoG is not only about empirical data.

“Center of gravity is also one of the measurements that is set by feel,” Adams says.

So how can a clinician balance both client demand and proper positioning so that clients get the most out of their mobility systems?

Science Behind CoGThe fi rst step to setting CoG is fi guring out what it is exactly. By defi nition, CoG refers to the point at which the weight of the wheelchair is balanced.

“Objects are balanced when the weight is evenly distributed,” says Kay E. Koch, OTR/L, ATP, rehab clinical consultant for Invacare Corp. “The center of gravity is this balance point.”

That might be a hard concept to visualize. Instead, think of CoG as a

balanced seesaw. If no one is on the seesaw, the CoG is in the middle of the seesaw. If people of different weights are on each end of the seesaw, then all of the different weights must be taken into consideration. The CoG will be where the seesaw is balanced, which will be closer to the end of the heavier person.

In this example, the seesaw represents the wheelchair, which has its own unique CoG. But when you add a person to the chair, just like with the seesaw, the CoG changes. A wheelchair has a CoG low to the ground, but when the chair is occupied, the CoG shifts higher. As you can imagine, this shifting of balance can distort stability. That’s one reason it’s so important to get CoG right.

To illustrate the point, Koch uses the example of moving the rear wheels on a manual chair.

“When the rear wheels on a manual wheelchair are shifted forward, the center of gravity is changed, making it easier to pop a wheelie. If the wheels are shifted backward, the center of gravity is changed, making the wheelchair more stable and harder to pop a wheelie,” Koch says. “By understanding how this relates to performance, stability can be changed to help the client navi-gate his or her environment.”

Of course, stability isn’t the only factor to consider with CoG. In fact, stability has a negative relationship with ease of propulsion, which might spell trouble for manual users, especially on an incline and decline. For example, if more effort is required to change direction, fatigue is increased, Adams says.

“The less energy we have to spend steering, the more is left over to generate speed or cover more distance,” he says, which can dramatically affect how easy it is for someone to navigate his or her environment.

Of course, when the body moves in tilt or recline or when maneuvering

The Science Behind Center of Gravity & Tips on Getting the Right Adjustment By Elisha Bury

S E A T I N G & P O S I T I O N I N G H A N D B O O K

mobilitymgmt.com6 2014-2015 Seating & Positioning H A N D B O O K

Getting Lost in Gravity?

What Does the Research Show About Center of Gravity? In 1991, Edward D. Lemaire and colleagues published a

study in the Journal of Rehabilitation Research and Development regarding center of gravity and rolling resistance for tilt-seat

wheelchairs. The study showed that moving the rear wheels

toward the front of the chair reduces rolling resistance and

decreases the rearward tip angle.

“These facts are directly related to the center of gravity posi-

tion since, as the wheelbase is decreased, the center of gravity

moves closer to the rear axle,” explains Kay E. Koch, OTR/L,

ATP, rehab clinical consultant for Invacare Corp. “This results

in more weight being centralized over the rear wheels, thereby

reducing the rolling resistance. However, when the wheelchair

is tipped backward, the center of gravity does not have as far to

move before the wheelchair passes the balance point (the point

at which the center of gravity passes behind the rear axle).”

Koch also notes that a longer wheelbase increases the rear-

ward tip as well as rolling resistance.

This research can help clinicians decide on the appropriate

wheelchair confi guration during setup by promoting safety and

minimizing function loss, Koch says. ●

obstacles in the environment, CoG will change again, Koch says. Therefore, a clinician must consider more than simply the client’s weight

when determining CoG.

Benefi ts of the Correct CoGSo what does this complicated measurement mean for clients, and why is it so important to get it right?

As you already know, CoG can have a big impact on a client’s everyday effi ciency in terms of propelling a manual chair.

“These adjustments can provide better wheel access, which leads to more effi cient propulsion even if only minimal adjustments are made,” Koch says.

Everyday effi ciency becomes especially important as clients age or for clients with the most limitations, including those with weakness, reduced endurance and impaired balance, Koch says.

CoG can impact many other aspects of a client’s life, however, including shoulder/wrist/fi nger/joint health, fatigue, comfort, posture and confi dence, Adams says.

For example, if a chair is too front heavy, a user might be in danger of incurring a shoulder injury because the chair is harder to turn, Adams says. Likewise, if a chair is too unstable, a user will have to worry about tipping over backward, resulting in posture issues or even loss of confi dence.

“If feeling like tipping over backward is a constant concern, that can easily result in an enormous amount of anxiety,” Adams says.

Shoulder injuries can be particularly concerning for someone with lower-extremity amputation. For these clients, “the adjustment in the center of gravity is crucial,” Koch says, as it will reduce the stress on the upper extremities.

Setting It Right: Manual ChairsSetting CoG for manual chairs requires a fi ne hand. What clinicians are attempting to do is set the CoG for the optimal weight distribution over the back wheels and front casters, Adams says. As easy as that sounds, there are many ways to go about it.

“Getting the weight distribution somewhere in the 80/20 rear/front range is a good starting point for most riders,” Adams says. “From there, small adjustments can make a big difference.”

Tina Roesler, PT, MS, ABDA, director of international sales at TiLite, says that ideally the rear wheel would be in line with the shoulder or slightly forward of the shoulder to maximize propulsion.

Another way to determine CoG, Roesler says, is to look at the height of the front caster when the person is in a balance position in the chair.

“When holding the wheelie, the front caster should really be no more than 3" or 4" off the ground for safety reasons,” she says.

Koch says that clinicians must take into account the user’s height, weight and body type, strength and balance, position in the wheelchair, and the wheelchair and seating system when determining CoG adjustments. She recommends evaluating the user’s skill level and then moving the rear wheel forward in 1/2" increments.

Center of gravity (CoG) is the point in which the weight of an object is balanced. For example, if a seesaw is empty, the CoG is in the middle of the seesaw. If people with different weights occupy the seesaw, the CoG is closer to the heavier person. Likewise, a wheelchair has its own unique CoG. When a person occupies a chair, the CoG changes. A wheelchair has a CoG low to the ground, but when the chair is occupied, the CoG shifts higher.

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mobilitymgmt.com Seating & Positioning H A N D B O O K 2014-2015 7

Adjustable center of gravity is one of the most critical adjustments that any chair should have

—Tina Roesler, PT, MS, ABDA, TiLite

Of course, Adams says the battle between stability and maneuverability is a tough one. “Testing the setting in as many different environments as possible is helpful, and making sure that the testing happens in a safe envi-ronment and in small steps is critical.

“I always try to make gradual changes (1/2" at a time) and do repeated tests — steering around pylons, going up and down ramps and curb cuts, doing a wheelie off of a curb, and other things that are real-world tests. I’ll often install anti-tippers, but set at a height where they would only touch as a fail-safe,” he says.

CoG isn’t a set-it-and-forget-it adjustment. Roesler says adjustments to CoG should progress forward over time as a new user acquires skills.

She says that although the research shows that a forward CoG is better, it’s important to consider the stability of the user.

“It is important to remember that stability is relative to the user, and a new rear-wheel position may require some skills training,” Roesler says. “We need to give the client time to acclimate to the more forward wheel. We shouldn’t just move the wheel rearward because their wheels are popping off the ground when they fi rst try to push. We need to give instructions on how much force to use and how to propel correctly.”

Finding the CoG in PowerUnlike manual chairs, power chairs do not require exact measurements for CoG. Instead, the drive-wheel confi guration determines CoG for a power chair user, explains Magdalena Love, OTR, ATP, at Permobil.

“Ideally, you want the majority of the individual’s weight over the drive-wheel tire,” she says.

To do so, the clinician will have to take into account the user’s weight and weight distribution. For example, in a rear-wheel-drive confi guration, a user with a lot of weight anteriorly, such as a client with lower-extremity edema, will have that weight positioned over the front casters.

“Consequently, the drive wheel will not be getting as much traction as it needs for optimal performance. When using power seat functions such as tilt and recline, all the weight of the user and seating system shifts backward, potentially making the system have a tendency to rock backward. This sensa-tion often is very alarming for individuals to experience — potentially leading to a decreased likelihood of completing pressure-relieving activities,” Love says.

On the other hand, that same user might have other issues in a front-wheel-drive chair.

“Depending on the individual’s weight distribution, the wheelchair may have a tendency to rock forward if the user does not tilt back,” Love says. “This is especially true when going downhill or if there is signifi cant lower-extremity edema. However, the system would be well balanced during seat function use.”

The mid-wheel-drive chair might be the best option for this client, as it would provide the most stability with the least number of restrictions during driving and power seat function use, Love says.

Koch says that when the drive wheel is behind the user’s CoG, such as on a rear-wheel-drive system, the chair will be stable but have a larger turning radius. The front-wheel-drive confi guration provides stability with a tighter turning radius, and “the drive wheel in the center or the mid-wheel drive has the user’s center of gravity over the wheelchair and has the tightest turning radius,” she says.

When determining the best drive system, clinicians must also consider the

user’s driving skills and environment. That often means explaining the differ-ences among rear-, front- and mid-wheel drive. Love uses the example of a person driving down a hallway and then turning right into a room. She says the rear-wheel drive requires a wide turn, but a wide turn with front-wheel drive would swing the rear casters into the wall. Love recommends a trial of the equipment in the home or community as well as specifi c training on driving techniques.

So what happens when the chair is confi gured with power tilt, power recline or both?

“The bases are designed to accommodate this change created by the seating system function, and the actual center of gravity on the base remains the same,” Koch says.

Even on manual chairs with a tilting seating system, the system is designed with fi xed CoG changes that do not need adjusting, she says.

A Word on AdjustabilityAdams tells the story of a client who is a professor at a local university and an experienced manual chair user. She ordered a fully welded chair. After the chair arrived, Adams did the fi nal fi tting and tweaks, and the client was happy. The professor then picked up her backpack and fl ipped over.

“We had done the eval and ordered the chair midsummer, and it didn’t come in until mid-September, after school had started,” Adams explains. “Her backpack was now fi lled with books and papers, which made the CoG that we ordered unmanageable. Her chair was just way too tippy with her backpack mounted. Her requirements from September to April were about 2" off of her requirement during summer break from May to August.”

Although Adams found a solution that required mounting some of the professor’s books to the front of the chair, this situation convinced him that adjustability is critical, even for experienced users.

Roesler agrees. “Adjustable center of gravity is one of the most critical adjustments that

any chair should have,” she says. “The position of the wheel would dictate someone’s long-term function and their ability to function within their environment.”

Changes in cushion height, growth, weight gain, weight loss, skill development and others can all have profound effects on the CoG setting and vice versa

— Jeff Adams, Icon Wheelchairs

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mobilitymgmt.com8 2014-2015 Seating & Positioning H A N D B O O K

have dramatic benefi ts.”As the client changes over time, CoG might also need to change. For

example, weight gain, changes in environment, and progression or regression of disability might warrant an adjustment.

Even age can be a motivator for CoG adjustments. “Older clients may feel less comfortable with a more tippy chair, while

young kids, as they progress and propel better, may require center of gravity more forward,” says Roesler.

Sometimes the adjustment is all about the client’s personal needs as well.“Personal preferences may also change after a signifi cant time spent in a

powered mobility device,” Love says.

Final Thoughts on CoGPerhaps the most predictable piece of CoG is that it is never predictable. Even after years of adjusting CoG, Adams is surprised occasionally.

“We had a customer about 18 months ago who I had known for over 15 years. She was requesting a chair with a very aggressive rearward CoG and anti-tippers, which I had never known her to use. We were talking about what she wanted in terms of her confi guration, and I asked her why she was confi guring her chair in such a different way than her previous chairs,” Adams says. “She eventually told me that she was expecting a child and was going to be going through an enormous personal CoG change.

“I promise that in any of the design sessions I’ve done, in all the late nights that I’ve spent trying to understand the ever-elusive perfect combination of theory versus practical when it comes to the design of manual wheelchairs, I didn’t consider getting pregnant.”

Adams’ point: It’s impossible to imagine every possible scenario. There’s always a chance something new will come up in a client’s life that will require an adjustment in CoG.

Ultimately, helping the client live a better life is at the heart of the CoG adjustment.

“Center of gravity combined with proper chair fi t and confi guration will have a huge impact on everyday effi ciency. If we can optimize fi t, center of gravity and confi guration, the client will be able to maximize their potential and have better skills acquisition,” Roesler says. “It will help them integrate better into their community and enjoy a better quality of life long term.” ●

Adams says that even a 1/4" can make a difference, especially because “if someone lives in Topeka or San Francisco, the practical application of the theoretical setting of the CoG can be wildly different.”

In fact, the ability to adjust CoG on the go would be ideal.“One of the things that often messes up the center of gravity of my

personal chair is having to carry something — groceries or laundry. Or horsing around with my nephews on my lap causes the CoG of my chair to be very front heavy, and my chair becomes cumbersome to maneuver,” Adams says. “On the other hand, if I’m carrying something up a ramp and am prevented from leaning forward, my chair becomes way too unstable. Being able to make on-the-fl y changes to the CoG while out in the real world could

When determining center of gravity (CoG) for a power chair, consider the drive-wheel confi guration. “Ideally, you want the majority of the individual’s weight over the drive-wheel tire,” says Magdalena Love, OTR, ATP, at Permobil. Consequently, a rear-wheel confi guration places the weight over the rear wheel, which provides stability. A front-wheel confi guration places the weight over the front casters, which could result in less stability depending on the user’s weight distribution. The mid-wheel drive confi guration places the weight right in the center of the chair, giving the user the benefi t of stability as well as a tight turning radius, says Kay Koch, OTR/L, ATP, rehab clinical consultant for Invacare Corp.

The Importance of Center of GravityYou might be wondering, What’s all the fuss about center of gravity (CoG)?

According to Jeff Adams, president/CEO of Icon Wheelchairs,

many clinicians are starting to realize how critical the fi t of the

chair is, especially adjustments such as CoG, seat angle and

back angle.

“Examining the center of gravity position helps illustrate how

the confi guration can also be much more important than the

overall weight of the chair,” Adams says. “It’s well understood

in the industry that the goal when setting the center of gravity is

to try to keep the loaded weight of the front of the chair as light

as possible, while maintaining a usable center of gravity — in

other words, we want the chair to be as tippy as possible, as

long as it’s safe. Everyone who is familiar with manual chair

setup knows that when the center of gravity is too far forward

(meaning that more weight that is being carried by the front

wheels) the chair loses maneuverability.

“Imagine a scenario where a rider with a theoretical ideal

center of gravity setting of 3" (rearward) from the center of

the rear axle to the front of the back tube is asked to choose

between two chairs, one that weighs 15 lbs. and one that

weighs 5 lbs. more. The heavier chair is set up to be idealized

for maneuverability, with the center of gravity set at 3", and the

lighter chair set at only 2" . The 1" difference in the setting will

make the lighter chair more diffi cult to steer and will cause

strain on hands, elbows and shoulders.”

Ultimately, a properly confi gured chair trumps a lighter chair

that’s not set up correctly every time. ●

Elisha Bury is a freelance writer and editor who has worked in the mobility sector since 2005. She previously served as the editor of The Mobility Project and associate editor of Mobility Management.

Getting Lost in Gravity?S E A T I N G & P O S I T I O N I N G H A N D B O O K

mobilitymgmt.com Seating & Positioning H A N D B O O K 2014-2015 9

It’s simple: When building a seating system, measure the client to determine how wide and deep the wheelchair seat should be. Backrest height can be determined by the client’s stability and personal pref-erences. Get those three measurements — width + depth + height — and you’re ready to go.

Right?Of course, in the real world, it’s not that easy. A number of factors, some

clinical and some environmental, can infl uence how wide and deep a seat should be for a particular client, and how high the backrest should be.

Once funding sources chime in, the noise level rises. With their insis-tence on product longevity, reluctance to pay for replacements, and shrinking budgets, payors can seem to have the loudest voices of all.

So how can ATPs and seating clinicians work so that clinical, functional and funding concerns are all diligently addressed?

Why Seat Size MattersTo a world accustomed to standard-sized hospital wheelchairs, being so meticulous about seat width and depth as well as backrest height may seem strange. Why are exacting measurements so critical to functional success?

Generally speaking, clinicians advocate for wheelchairs with small foot-prints, which directly correlate to the size of the wheelchairs’ seating systems.

Tricia Garven, PT, ATP, clinical applications manager for ROHO Inc., notes two main advantages of a smaller footprint — and thus of a properly sized seating system.

“First of all, shoulder-to-wheel alignment for shoulder preservation,” she explains. “If your arms aren’t having to reach out to the wheels, then you’re going to be set up for more success in terms of less pain and better alignment.

“But then also there are accessibility issues in the environment — getting through doorways, turning around in restaurants — because the wider your chair is, the bigger your turning space is. Being in crowded places, getting into bathroom stalls — the handicapped stall isn’t always there or available.”

A seating system that fi ts properly is especially important to the consumer who self propels, Garven says.

“You don’t want them to have to bend their elbows outward,” she explains. “Of course they’re going to be bending their elbows to push, but

you don’t want them to be reaching out, opening up the armpit.”The same goes for pediatric wheelchair users, says Lauren Rosen,

PT, MPT, MSMS, ATP/SMS, program coordinator, Motion Analysis Center, St. Joseph’s Children’s Hospital of Tampa (Fla.).

“If you’ve got a kid who is a manual chair user and the chair is too wide — the [smallest children] already have trouble reaching the wheels and handrims as it is. Imagine the handrims even further out by making the chair too wide, and they can barely touch the wheel itself.

“Also just by doing that, you’re pre-disposing those kids to shoulder problems because the research tells us the more you abduct your shoul-ders, the more damage you can do from propulsion.”

Children who use power chairs can also run into access problems if their seats are wider than necessary.

“You can’t reach to the joystick, you can’t reach to the armrest,” Rosen notes. “If the chair is too wide, you can’t reach everything. In some cases, we will make the power chair a little bit wider than we would a manual chair and just put a bunch of hip guides up against the kid, but they’re still reaching for the joystick, which makes it more diffi cult to operate the chair.”

And that diffi culty could be costly to a child trying to demonstrate that he or she could indeed be a successful power chair operator.

“With all of the things coming out about what somebody should be capable of doing before qualifying for a chair — if you put the joystick farther away, any of us would have a harder time of navigating successfully through a maze or cones or whatever,” Rosen says. “It just makes it harder to control the chair if you’re having to reach too far.”

As for determining how deep the seat should be, Rosen says, “If you choose a seat depth that’s too large, you end up with a kid who has to slide forward, so they sit with a posterior pelvic tilt. You’ve got the problem too that a lot of the kids who use wheelchairs are kids with cerebral palsy who have spasticity, so most of those kids have really tight hamstrings. And so they’re already needing to tuck their feet underneath them as much as they can; that alone is causing them to sit with a posterior pelvic tilt. You add a too-deep seat depth, and you’ve got a kid who’s kind of lying down.”

Regarding how high a back should be, Garven says, “You want backrest height to be as much support as necessary without being too much. Too much back height, too much anything in the back, is probably going to limit upper-extremity movement, and it may even hinder their ability to have small corrections with what balance they do have if that backrest is too high. It might not allow as much movement as they personally have.”

Rosen says the thought process is much the same for kids.

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Finding a Formula That Works for Clients, Payors & the Seating Team

mobilitymgmt.com10 2014-2015 Seating & Positioning H A N D B O O K

“If it’s a kid who has good trunk [control], I’ll do the backrest just like I would do with an adult and try to go right below the scapula,” she says. “If I’ve got a kid with [less trunk control], then we’ll cheat a little bit higher. I try to never go [up to] the shoulder height. I try to always stay at least an inch or two lower, even in those kids. The kids who have really bad trunk control will end up with a solid back and laterals, so those tend to be a little bit taller to give you more support and room.

“I don’t want the back getting in the way of propulsion. It’s the same as with an adult: If my scapula can’t move like it needs to move, I can’t propel nicely, I can’t do everything I need to do because I hit my chair every time I go to push.”

Sizing Up Tomorrow’s MeasurementsIf clients generally do better with seating that’s just right instead of too big, why not just build systems that fi t clients exactly the way they are?

In a word: time. Garven and Rosen both indicated that payor expecta-

tions force the seating team to make their best estimates in determining whether today’s “perfect size” will also work years into the future.

Garven notes that looking into the future can be particularly diffi cult for clients with new diagnoses who may need larger seat widths down the road — and possibly before funding sources are willing to buy new equipment.

“It’s a challenge, and that’s where the therapist interview with the client and family members, the whole healthcare team, is important,” she says. “When somebody’s fi rst injured, it’s tough. If somebody’s been injured for a long time, then it’s ‘What is your history? Have you been gaining fi ve to 10 lbs. a year?’ Because we can probably expect that to continue unless they’re going to do something about it. If somebody says, ‘Yeah, I’ve been gaining weight, but I’m going to quit’ — you have to be realistic.”

Seating team members may have to dig deeper for information when the client is newly diagnosed.

“I think the real challenges are the clients who have gained or lost a ton of weight in the hospital,” Garven says. “You’re sort of guessing: Are you going to keep this weight, or are you going to lose some more? I know you have a spinal cord injury so you’re going to atrophy, but that doesn’t neces-sarily mean your belly’s going to get smaller.”

Understanding the client’s lifestyle before diagnosis, as well as their intentions post diagnosis, is also important.

“What do you expect, person in the wheelchair, to be doing in two to three years?” Garven asks. “What do you think you’re going to be doing?

“I think that’s also where the whole multi-disciplinary team becomes

Everybody is planning for a ton of growth that these kids just don’t have

— Lauren Rosen, PT, MPT, MSMS, ATP/SMS

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S E A T I N G & P O S I T I O N I N G H A N D B O O K

Width + Depth + Height

mobilitymgmt.com Seating & Positioning H A N D B O O K 2014-2015 11

involved because especially if somebody is newly injured, you’re going to have access to probably neuropsychology, to nursing, to physicians. Everybody has conversations with this person, and they’re going to know — how is this guy coping? Because even the most active, fi t person can become severely depressed, and that’s going to lead to sedentary, static behavior, eating, things like that.”

Anticipating Kids’ GrowthWith children, from infancy right through their teens, the challenge can be in anticipating how much growth they’ll experience before they’re able to qualify for their next wheelchair or seating system.

“All the pediatric chairs have some kind of growth built into them,” Rosen says. “In the manual chairs, most of them have 2" or 3" of depth and 2" or so of width growth built into the system, where you just have to change out some parts and all that. If I’ve got to grow a chair during the fi ve years, insurance is willing. Sometimes with older kids in manual chairs, if we do a rigid-frame chair, most manufacturers have a growth program where if you outgrow the frame, they will send you a new frame for cost, and it’s counted as growth, not as a whole new purchase.”

But the seating team must still determine the size of the initial system.“The big thing that I’ve looked into is growth in kids with disabilities,”

Rosen says. “Kids with disabilities don’t grow as fast — [not] at the same rate as able-bodied kids. The thought process is ‘They’re going to grow a ton in the next fi ve years.’ Our kids don’t grow as much. They especially don’t tend

to grow in width as much. In kids with cerebral palsy, their bodies are working so hard all the time that their metabolism is off the charts. So a lot of those kids don’t have as much of a tendency to gain a ton of width growth; they tend to grow in depth more. The measurement that seems to be the most off on kids is the width. Everybody is planning for a ton of growth that these kids just don’t have.”

As a general rule, Rosen says she asks ATPs to build in an inch of width growth for a pediatric self-propelled chair.

“For an adult chair, for somebody who propels, I tend to put it at the width the person is. But with kids, I will usually give them an inch, or if they’re a 10.5, we’ll go 12,” Rosen says.

“In power, I will probably give them 2" only because it’s not as critical. I’m not giving them more than 2". That’s the most I will give anybody, width wise, on a power chair. I don’t want them reaching, and I don’t want them to feel like they’re swimming in the chair.”

Rosen says her clients haven’t outgrown their chairs and seating systems, despite relatively conservative widths. And she has another reason to prescribe seating that’s not overly large: It can be a self-fulfi lling prophecy.

“A lot of the kids I see around here are in ‘diagnosis seating’ — where every kid has the exact same chair and the chairs are too wide,” she says, adding that those clients are overweight, sometimes very signifi cantly.

Noting friends who have spina bifi da and who are in excellent physical condition as elite athletes, Rosen says, “I know that spina bifi da as a diag-nosis does not lead to being fat. So I look at chair setups and how hard it is

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S E A T I N G & P O S I T I O N I N G H A N D B O O K

mobilitymgmt.com12 2014-2015 Seating & Positioning H A N D B O O K

Trends: Cushions Get the “5-Year” TreatmentMuch of the anxiety of choosing the width/depth/height for

a seating system stems from payors’ insistence that the

system last a certain amount of time — a period that continues to

lengthen as budgets and allowances continue to shrink.

Tricia Garven, PT, ATP, clinical applications manager for ROHO

Inc., says durability expectations for seating systems and compo-

nents are increasingly being applied even to seat cushions. In

the past, funding sources were relatively amenable to replacing

cushions more often than wheelchairs, for example. But now,

more payors are holding cushions to the same fi ve-years-of-usage

parameters that wheelchairs have.

“It is getting tougher,” Garven says. “[There’s a] fi ve-year

replacement rule even for cushions, which typically were sort of

an exception. Maybe the [fi ve-year] idea kind of existed, but the

enforcement never did, for sure.”

Garven adds that the trend is occurring among various payors.

“If anything, some of the insurances are even tougher than

Medicare,” she notes. “We sort of treat Medicare like they’re the

worst ones, and they are defi nitely trend-setters. Lots of people

copy them, but there are plenty of insurances and Medicaids in

different states that are even tougher. Or their allowables and such

are even lower. It’s defi nitely going that way for whatever funding

source isn’t there yet.”

One of the translations for ATPs might be choosing seat cush-

ions and mobility components with greater durability, Garven

says, so the products can last through fi ve years of rigorous use.

“Patient education is important for making it last that long.

Choose a product that you expect to last that long, and if [they’re]

a really hard and heavy user, anticipate that in your frame selec-

tion. If the cushion needs to last this long, it needs to be cleaned

often. Choose something that can be cleaned often, whatever that

might be.”

Knowing differences between products and codes could also

be crucial for sound decision-making.

“General-use cushions have a 12-month warranty; that’s

the Medicare standard, that they have a 12-month warranty,”

Garven says. “Twelve months to 60 months — quite a difference.

[General-use cushions] are not expected to last that long, so

if somebody does qualify for a better, longer-warranteed-type

product, get it. They’re going to be using the chair for two or three

or four or fi ve years, so understand that you have to choose the

correct width, but also the durability.” ●

to push. For a kid, if everything is hard to push, do I want to go out and try to chase the other kids in the neighborhood who are running, or do I want to sit on the couch and eat the Cheetos?”

In that way, Rosen says, wheelchairs that are wider than they should be can cause vicious circles: propulsion problems that lead to sedentary life-styles, weight gain and, yes, larger seating widths.

“If every day, everything about moving yourself around is diffi cult because your chair setup is bad, then we’re not encouraging kids to be active,” Rosen says. “We’re encouraging the couch and Cheetos. My idea of making the chair lighter weight and more dialed in to a kid is going to make them more functional and give them a better quality of life than doing the diagnosis seating where everybody gets the same chair.”

Finding the Sweet SpotSo how can ATPs and clinicians choose measurements that meet the needs of clients now and later as well as the long-term demands of payors?

Both Rosen and Garven take a “less is more” approach, in which they gather all the information they reasonably can, then try to dial in seating to create as compact an overall footprint as they can.

Referring to backrest heights, Garven says, “That one to me is a little bit more forgiving. The height on most of your chairs comes in ranges. Unless you’re dialing in a wheelchair and getting something that’s totally fi xed, most new chairs have a back height range that you’re choosing. Also if you’re attaching a solid backrest, you have a little bit of play there, I’d say up to an inch or an inch and a half, or 2" depending on the height of the backrest because you can move it down. You just don’t want to move it up so high that you lose contact with the pelvis, which is what’s helping to create your posi-tioning. And that’s how the backrest can support healthy skin and posture.”

As far as estimating seat depths and widths, Garven suggests getting opinions of other healthcare professionals working with the client — espe-cially a newly diagnosed one — but also having an honest conversation with the client about his or her impact on the situation.

“I think patient education is important, too,” she says. “‘Look, I’m getting you this wheelchair because this is our expectation; don’t blow it. Don’t go home and eat only junk food. You need to eat healthy, and this is why: You’re not getting a new wheelchair for a long time.’

“There’s no benefi t to not being honest and realistic with the funding challenges: ‘Understand how much this costs. Insurance is going to pay for it, but they’re not going to do this again quickly.’ [The client] can’t say they want a 15"-wide chair when they’re measuring 18" wide. But if you’re sort of bouncing between 18" and 19", or 18" and 17", having them be informed and having everybody involved and discussing it is going to be helpful.”

Rosen says she takes a look at her pediatric client’s family to estimate how much her client will grow. “If the family is a skinny family, chances are the kid’s going to stay skinny. There’s genetics involved in how we grow and what kids are going to look like, so I do look at the family and if siblings are there, I think about that. I’ll ask, ‘How tall is Dad?’ so we know what people’s propen-sity for growth is. If the entire family is 5’2”, a kid who’s not weight bearing most of the time isn’t going to be 6'10".”

Still, with every child, with every client, Rosen acknowledges the possibility that the improbable might happen.

“The biggest thing to making that determination is treating them like an individual and looking at everything,” she says, “Not just saying, ‘With every kid, I put in an inch of growth’ or ‘With every kid, I automatically do this or that.’ With seat depth, we’ll do their exact depth on the younger kids. With the older kids, we’d do closer to what we’d do with an adult and give them a little bit of room behind the leg.”

She adds that a well-fi t chair, one that’s not too deep or too wide, has less tangible benefi ts, as well.

“I do believe that part of the reason for doing the chairs the way that I do them is so that you are seeing the kid and not the chair. I don’t have the medical necessity of that, but realistically the more you see the kid and less the chair, the more you see the kid as a person. There’s less of a stigma attached to having a chair.” ●

S E A T I N G & P O S I T I O N I N G H A N D B O O K

Width + Depth + Height

mobilitymgmt.com Seating & Positioning H A N D B O O K 2014-2015 13

S E A T I N G & P O S I T I O N I N G H A N D B O O K

Airpulse PK2Clients with or at risk for pressure sores can now take the

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Solara 3G Wheelchair with Matrx SeatingPB&J. Wine and cheese. Solara 3G and Matrx are just

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Low Profi le Amputee SeatPreventing knee fl exion contractures is the goal of the Low

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ease transfers. The seat can be removed from the chair and

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Drive Medical Design & Mfg. (516) 998-4600

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Convaid TrekkerTrekker takes adjustability

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Product Revue

mobilitymgmt.com14 2014-2015 Seating & Positioning H A N D B O O K

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S E A T I N G & P O S I T I O N I N G H A N D B O O K

TRU-Balance 3 Power Positioning SystemsDesigned to fi t like a suit, the TRU-Balance 3 Power

Positioning System offers options to truly tailor the system

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JAY Positioning SupportsWhat you’re looking for in positioning supports, the JAY

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New to the line are single and

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Sunrise Medical (800) 333-4000

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Company Name Page #

Aquila Corp. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Dynamic Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Ottobock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Permobil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Pride Mobility Products/Quantum Rehab . . . . . . . . . . . . . . . . . . . . . . . . . 3

Stealth Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Symmetric Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Thomashilfen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

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